Healthcare Provider Details

I. General information

NPI: 1134850639
Provider Name (Legal Business Name): BERNADETTE POWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1180 NEWFIELD AVE
STAMFORD CT
06905-1409
US

IV. Provider business mailing address

1180 NEWFIELD AVE
STAMFORD CT
06905-1409
US

V. Phone/Fax

Practice location:
  • Phone: 314-888-5233
  • Fax: 844-689-5311
Mailing address:
  • Phone: 314-888-5233
  • Fax: 844-689-5311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4441
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: